Anthem limits provider network in Maine, part of national trend toward narrow networks

Legislators, hospital officials and others expressed shock and chagrin last week when Anthem Blue Cross Blue Shield announced that the coverage it would sell next year to individuals on and off New Hampshire’s health insurance marketplace would include only 16 of the state’s 26 general care hospitals.

Concord Hospital and Southern New Hampshire Medical Center, two of the largest in the state, are excluded. As first designed, the plan left all of Coos County without access to maternity care.

New Hampshire officials maybe shouldn’t have been surprised; Anthem’s network for the marketplace in Maine, announced in July, will exclude six of the state’s hospitals.

It’s what’s called a narrow provider network, though Anthem’s spokesman used the term “focused” instead.

By any name – narrow, focused or limited – the new network structure is a growing trend far beyond northern New England, and beyond the state marketplaces.

The move gives insurers leverage in negotiating reimbursements to care providers, which can help lower premium costs. Anthem officials said the New Hampshire marketplace plan premiums would be 25 percent higher if all hospitals in the state were included.

In total, Anthem officials expect about 10 percent of their customers in New Hampshire to be on the narrow network next year.

In Maine, about 17,500 people purchase individual insurance plans through Anthem, said Doug Dunbar, spokesman for the Maine Department of Professional and Financial Regulation, which includes the Bureau of Insurance.

About 7,100 of them would be affected by the narrower network, he said. Whether Anthem can require them to switch onto the new network isn’t clear yet, but a decision could come as soon as today, after a hearing at the bureau.

The other insurer offering plans on Maine’s exchange next year is a nonprofit, the new Maine Community Health Options.

The group has contracts with 34 of Maine’s 38 hospitals and is on track to sign up the rest before the end of the year, said CEO Kevin Lewis.

The state marketplaces – also called exchanges – were authorized by the Affordable Care Act as places where individuals and small businesses could shop for insurance and find tax subsidies to help pay for their premiums.

Maine is one of 27 states where the federal government will build, run and promote the marketplace; New Hampshire has entered a partnership with the federal government for the undertaking.

People and businesses can begin enrolling in the plans Oct. 1, and the coverage will be effective Jan. 1.

Information is currently available about only some plans in some states, but of the plans filed so far, almost half would be considered narrow networks, according to an article last month in the industry publication Modern Healthcare.

“In states that have announced so far, we’ve seen that and we expect it in the states to come,” said Robert Zirkelbach, spokesman for America’s Health Insurance Plans, the national trade association representing the health insurance industry.

He said the move is not a return to the HMO model of the 1990s, when insurers limited access to specialists and hospitals.

“Then, the effort was focused on bringing down costs. Now, we have, ‘How do we make sure patients are getting quality care, getting a good value,’ as the central focus,” by choosing providers for the networks based on performance metrics as well as negotiated reimbursement rates, he said.

Assurance that providers were selected based on performance would be important to employers determining whether they want to sign up for a limited network, said Karen Linscott, chief operating officer and acting CEO of National Business Coalition on Health, which represents employer groups that purchase health care.

“Our members are more supportive of narrow networks if the criteria include provider quality, not just costs. However, the reality continues to be that health care costs are unsustainable,” she said in a statement.

Information about whether Anthem used quality metrics in building the network for New Hampshire’s marketplace plan, and if so, what they were, wasn’t immediately available.

“The fact that a hospital or provider was not chosen for this network is not at all a reflection of Anthem’s relationship with that provider. Anthem views all of its contracted providers as high quality,” Christopher Dugan, a spokesman for Anthem in New Hampshire and Maine, said in a statement.

(Sarah Palermo can be reached at 369-3322 or spalermo@cmonitor.com or on Twitter @SPalermoNews.)

The joint fiscal committee approved New Hampshire’s planned application for expanding Medicaid yesterday. The federal Centers for Medicare and Medicaid Services must approve the proposal, which would extend …